Healthcare Provider Details

I. General information

NPI: 1700861242
Provider Name (Legal Business Name): CHILDREN'S SERVICE CENTER OF WYOMING VALLEY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 S FRANKLIN ST
WILKES BARRE PA
18702-3808
US

IV. Provider business mailing address

335 S FRANKLIN ST
WILKES BARRE PA
18702-3808
US

V. Phone/Fax

Practice location:
  • Phone: 570-825-6425
  • Fax: 570-301-3330
Mailing address:
  • Phone: 570-825-6425
  • Fax: 570-301-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number100728011
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number100728011
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100728011
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number100728011
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number100728011
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100728011
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MRS. SHARON PISARCIK
Title or Position: CFO
Credential:
Phone: 570-825-6425